Quality Assurance - A lot done, a lot more to do...
created 01 December 2016
Where I’m coming from…
A few months ago, I took up the role of QA Lead for the JCST. Coming from the Irish system, I start with a different perspective from many UK colleagues. There is strength in diversity, however, and I believe we all have a lot to learn from one another.
How does the Irish system differ from that in the UK? For one thing, our training posts, and the training culture, have been less affected by the European Working Time Directive (although the pressure is now increasing). Partly due to this, and partly due to lower staffing numbers, there is no shortage of cases in trainees’ logbooks. In our own unit, the SpRs can expect to be involved in close on 1,000 operations in a year – with substantial consultant supervision! Having said that, we know that by comparison to the UK we are under-resourced, and the average patient in the UK requiring elective surgical services has a much better chance of being seen in a reasonable timeframe.
We have retained the system of 5-yearly SAC visits; we value these highly and wish them to continue.
In Ireland, surgical practice is still relatively free of domination by management, and consultants have reasonable latitude in determining the content of clinics and operating lists. One major difference between Ireland and the UK is one of size; within the surgical community, everybody knows everybody else, and at the level of clinical practice, my patients are often also my neighbours, cousins, friends – or at least acquaintances!
Against this background I come to my new QA role with a number of beliefs. I believe in leadership of surgical practice by the surgical profession. I believe that a surgeon’s first responsibility is to his/her patient, but he/she also has a responsibility to train the next generation of surgeons. In the past, we as trainees were often left to “sink or swim”. I believe this was an injustice to trainees and, more importantly, to patients. We should now demand that the trainer be prepared, as a routine, to scrub in with, and assist, the trainee in a graded way so that the trainee genuinely and safely achieves competence. Often a patient will ask me in the OPD: “will you be doing my operation?” My standard reply is “The actual operating may be done by a trainee, but I will be there with him/her ensuring that exactly what I want done gets done”. Most patients accept this, and it is up to me to honour that promise.
Finally, I believe in co-operation among our four Colleges, and between our two sovereign states. Understandably, some in the UK may forget that the JCST is a trans-national entity. It is, and in fact we in the surgical profession have the opportunity to set a headline for the wider community in co-operation and friendship between our nations.
The Quality Assurance System
Starting out into my new role I have been impressed by the work which has been done, and is being done, by Helen Lewis and the staff at JCST. I am grateful to my predecessor, Graham Haddock, for the energy and initiative he brought to the role and for his help at the time of the handover. Thanks to their work, we have a good system in place; the challenge now is how we could improve it further…
The purpose of all our efforts, of course, is to produce a trained surgeon who is competent, and possesses the knowledge, skills and attributes necessary to be fit for purpose. Of these, “attributes” are very important; many surgeons encounter difficulty in their careers not by lack of knowledge or operative skill, but by falling short in the so-called “human factors” in surgery – communication skills, leadership and professional values.
We must be able to state with certainty if a given doctor, on completion of training, is now a fully trained, fit for purpose surgeon, or, perhaps more importantly, if and why, in an individual case, this is not so. That is why I believe it is so worth our while getting the certification guidelines right. They represent a huge improvement on the situation in the past where certification was obtained essentially on time spent in higher training. Some of the specialty certification guidelines now include indicative numbers of surgical procedures and this is to be encouraged.
When working to “quality assure” the system that must produce such an appropriately trained surgeon, we need to look at individual training posts, training programmes and, as is now being appreciated, individual trainers.
A good training post should have sufficient quality and quantity of surgical throughput. There should be a culture of consultant supervision in theatre, wards and outpatient clinics, affording the trainees the opportunity for graded acquisition of expertise. There should be a good in-house teaching programme. The trainees’ timetable should be balanced, and in particular should allow some time for study and research. The hospital should provide educational resources and, in particular, library facilities.
A good training programme should ensure that trainees get the most out of what the region has to offer, with a balance of experience to cover all facets of the specialty. There should be a regional teaching programme to match the requirements of the curriculum. In future, it will need increasingly to include simulation as part of the training process. It should have an effective mechanism for assisting the trainee in difficulty.
Finally, the good trainer should above all be a role model for his/her trainees and should exhibit the highest professional standards in clinical practice. Obviously s/he must be a good clinician – no trainer can pass on knowledge or skills which s/he does not possess in the first place. S/he must demonstrate a commitment to training – in clinical practice by being there for the cases and being prepared to assist the trainee and guide his/her technical development; by being there in the clinic and being prepared to see patients with the trainee; and by involvement in the teaching programme and broader training activity. S/he should demonstrate engagement with the training process, by acting as a conscientious clinical or educational supervisor and by working with the trainee on the learning agreement and workplace based assessments.
How to get the information…
There are a number of means available to us to obtain the relevant information, and we need to make the best use of these. A lot of work has gone into the development of the JCST Trainee Survey, and I must pay particular tribute to the efforts of Helen Lewis and my predecessor Graham Haddock for this. We are reviewing the survey to make it more focused and user-friendly. I would appeal to trainees firstly, please, to complete the survey – we cannot act to improve things if we don’t have the information! Secondly, we would welcome comments as to what questions we should include – or delete - to make the survey more effective.
On taking up my role, I was surprised to learn that, to date, e-logbook information had not been included in the JCST QA process. To me it seems self-evident that it should be. We now intend to work on this obvious means of getting insight into the quality of training posts. The intention would not be to scrutinise the experience of the individual trainee, but to observe the pattern of operative experience afforded, to successive trainees, in the individual post. I believe the important elements to look out for include the quality, quantity and breadth of operative experience, and the level of supervision - in particular, the number of entries under “STS”!
I am delighted to see that work is progressing on a trainers’ portfolio within ISCP, in anticipation of the new GMC requirements for the recognition of trainers. I believe good trainers need to have their efforts recognised, and those who for whatever reason leave room for improvement should be alerted to the fact and given the opportunity to improve!
Information on training programmes provided by Liaison Members is highly valuable, and we need to examine ways by which we make this information pathway more effective.
Coming from my own background, however, it would be remiss of me not to mention the value of visits. I have seen this at first hand, firstly as a trainee and latterly as a trainer. The most important element of any visit is the confidential conversation between the visitors and the trainees. That is when the true picture comes to light. I am pleased to see that, in the UK, the GMC recognises the value of QA visits; we in the surgical community should contribute to the process whenever the opportunity presents itself.
Acting on information gained…
Obtaining and collating extensive information on the quality of training is all very well – but what use is the exercise if we cannot act on information gained to effect improvements?! In times past, the JCHST (as it then was) and the SACs had the “nuclear option” of withdrawal of training recognition; units and individual trainers lived in fear of this, and the five-yearly SAC inspection was a powerful instrument in focussing minds!
Now we have to look at other options, and perhaps a range of proportionate options, but we must be seen to be able to act effectively on information gained. For example, how otherwise can we expect trainees to be enthused about completing the survey?
Working closely with our colleagues in the Schools of Surgery (and other national equivalent bodies), we should aim to feed back to units, programmes and indeed individual trainers how they are performing. Good training should be rewarded by explicit acknowledgement and positive affirmation; if training leaves something to be desired, this should be highlighted so that improvements can be achieved locally.
I know that any effort to achieve real improvements based on QA data will require buy-in on the part of the SACs, their Liaison Members, and Training Programme Directors. I am delighted that in the near future there will be QA Leads on each SAC and I look forward to working with these key individuals.
As was once claimed by a certain Irish political party during an election campaign – “a lot done, a lot more to do”!
Mr Joe O'Beirne, JCST QA Lead